1. PLACE OF DEATH County: Breckinridge Vot. Pol.: Custer Inc Town: City: No. St. Ward: Registration District No.: 5315 Primary Registration District No: File No. 17200 Registered No: 2. FULL NAME: Lyon, Sophia Ann PERSONAL AND STATICAL PARTICULARS 3. SEX: Female 4. COLOR OR RACE: White 5. SINGLE, MARRIED, WIDOWED, OR DIVORCED: Widowed 6. DATE OF BIRTH: Sept. 13, 1827 7. AGE (yr. mo. da) (If less than 1 day, hours or min?): 83 yr 10 mo 13 da 8. OCCUPATION (a.) Trade, profession or particular kind of work: Housework (b.) General nature of industry business or establishment which employed: 9. BIRTHPLACE: Simson Co., TN 10. NAME OF FATHER: Moses Scott 11. BIRTHPLACE OF FATHER: VA 12. MAIDEN NAME OF MOTHER: Rachel Hardy 13. BIRTHPLACE OF MOTHER: VA 14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) Cleveland Allen (Address) Custer, KY 15. Filed July 28, 1911 REGISTAR: R. O. Penick MEDICAL CERTIFICATE OF DEATH 16. DATE OF DEATH: July 26, 1911 17. I HEREBY CERTIFY, That I attended deceased from (date): July 13, 1911 That I last saw him/her alive on (date): July 22, 1911 And that death occurred on the date stated above at (time AM/PM): 9 PM THE CAUSE OF DEATH was as follows: Anemia (Duration) Years: 1 Months: 10 Days: 26 Contributory: Old age (Duration) Years: Months: Days: Signed (M.D.): J. W. Meador Date: Address: Custer, KY 18. LENGTH OF RESIDENCE (For Hospitals, Institutions, Transients, or Recent Residents) At place of death (yr, mo, da.): In the State (yr, mo, da): Where was disease contracted, if not at place of death? Former or usual residence: 19. PLACE OF BURIAL OR REMOVAL: Lyon Cemetery DATE OF BURIAL: 20. UNDERTAKER: R. B. Lockhart ADDRESS: Custer, KY